Basic Information
| Provider Information | |||||||||
| NPI: | 1255337465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANTL | ||||||||
| FirstName: | EUGENE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 KANE ST | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061192110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605236421 | ||||||||
| FaxNumber: | 8605233701 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 ASH ST | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602823859 | ||||||||
| FaxNumber: | 8602828574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 07/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 019762 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1197623 | 05 | CT | MEDICAID |